Diagnosis: Shortage

Professional nursing was born of a shortage. The lack of
medical personnel on the front lines of the Crimean War in
the 1850s meant that British casualties were three times as
likely to have died from hospital-borne diseases as from battle
wounds. Through their efforts at sanitation, nutrition, and
personalized care, Florence Nightingale and her cadre of nurses
reduced the mortality rate in British military hospitals from
42 percent to just over 2 percent. This remarkable improvement
helped nursing to earn recognition as an essential element
of quality health care.

Nurses are just as critical to our health now as they were
during the Crimean War, but we still don’t have enough
of them. The American Hospital Association estimates that
in the nation’s hospitals, 126,000 registered nurse (RN)
positions—11 percent of the total—are vacant. Though
hospitals account for 60 percent of RN employment, the lack
of nurses extends far beyond the hospital setting. Nursing
homes in Massachusetts alone have about 900 open positions
for registered nurses. Other employers of RNs, from visiting
nurse associations to schools, are also scrambling for employees.
At the same time, the nation’s nursing schools turned
away nearly 5,000 qualified students in 2001 due to insufficient
faculty and clinical and classroom space.
The number of nurses is increasing every year, but not quickly
enough to keep up with the growing demand for their services.
The culprits are both long-term trends, such as expanded opportunities
for working women and the aging of the population, and new
factors like the effects of the cost-cutting imperative of
managed care. The result is that there are too few RNs to
fill all the available positions. And the problem promises
only to worsen; by the year 2020, New England is projected
to have 33 percent fewer nurses than we’ll need.

A day in the life

“The first thing I do when I get to work is eat breakfast.
I always eat at the last possible moment because it might
be five or six hours before I get to eat again,” says
Linda Huet, a registered nurse in the postoperative recovery
unit at St. Elizabeth’s Medical Center in Boston. Her
day is a hectic rush of listening to reports from the previous
shift, then checking in repeatedly with each patient to perform
clinical assessments and administer treatments and medications.
She adds, “Ninety-eight percent of the time I feel exceptionally
busy. There’s always a reason to stall lunch, and the
day goes by quickly.” At Hasbro Children’s Hospital
in Providence, lunchtime in the pediatric intensive care unit
is a particularly stressful point in an already frenzied day.
The busy work pace kicks into high gear as half the nurses
leave to eat their meal and everyone else’s workload
is doubled. “It can be mentally overwhelming for some
people to monitor double the patients in an intensive care
setting,” says Donna DuPuis, a registered nurse on the
floor.

There are over 2.2 million registered nurses in the United
States, making it the largest health care occupation. Nurses
may practice in almost any setting, from hospitals and nursing
homes to schools, corporations, and nonprofit agencies. Those
who work directly with patients are responsible for the day-to-day
monitoring and documenting of their patients’ progress,
as well as for administering treatments, medications, and
therapies. They are the first line of medical defense when
anything goes wrong, and they are also the first source of
professional comfort for patients and their families. Other
nurses work outside direct practice in patient education,
research, and administration. These nurses may run clinical
drug trials, teach patients how to use medical equipment,
or manage the workload of dozens of employees.

Nursing is a highly skilled profession, requiring two to
four years of schoolwork, a passing score on a national competency
examination, and continuing education and training. As a result,
starting wages for staff nurses are relatively high compared
to other professional occupations. The average new RN earned
around $31,000 per year in 1996, similar to the starting salaries
for engineers and much higher than the overall average for
new college graduates. Opportunities in the field are broad,
and the caring labor nurses perform means that they have a
direct impact on people’s lives every day. But even on
a good day, “nursing is physically as well as mentally
intense work,” according to Lisa Murphy, Huet’s
supervisor and the director of surgical services at St. Elizabeth’s.
Nurses complain that their wages do not grow adequately with
experience and do not reflect their high level of responsibility.
Every day, they face evening, overnight, and weekend work,
the possibility of contracting a disease or injuring themselves
on the job, and the emotional stresses of dealing with sick
people. Furthermore, they feel their work is underappreciated
by the public. Though a recent Gallup poll showed Americans
rate nursing as the occupation with the highest ethical standards,
nurses say this doesn’t translate into respect for their
work. Murphy says, “People think nursing is bed pans
and back rubs, or being a handmaiden to doctors. They don’t
understand the responsibility and the training that go into
it.”

Making matters worse, lately many RNs feel there aren’t
enough nurses to go around. “I spend much of my day trying
to make sure there are enough workers for each shift to cover
all the patients,” reports Murphy. “We’re maintaining
our quality of care, but on a day-to-day basis it’s challenging.
Our nurses are definitely busier.” Nurse managers like
Murphy across the country are having difficulty filling empty
positions, especially in specialty care areas such as intensive
care and emergency departments. “It’s a matter of
lack of human resources. We have no nurses to hire,”
says Veronica Hychalk, Vice President of Professional Services
at Northeast Vermont Regional Hospital in St. Johnsbury, Vermont,
and New England’s representative to the American Organization
of Nurse Executives. Because of the scarcity of staff, nurses
say they are now expected to work with more and sicker patients
than ever before. This has quickened their work pace and decreased
the amount of time they can spend with each patient. Insurance
regulations have increased the amount of paperwork they must
contend with. Additional use of temporary staff has meant
that nurses must spend more time training new workers on department
procedures. And if managers can’t find enough staff to
cover all the shifts, nurses may be asked or required to work
overtime.

Prescription for a shortage

Having more nurses on the job would probably help alleviate
some of these problems. But does this mean that there is a
nationwide shortage of nurses? It’s hard to say. There
might not be enough nurses overall, or we might have enough
nurses but need to better distribute them across specializations,
employers, or regions. We have no official economic definition
of a shortage to guide us, or even a consistently gathered
set of data that compares national staffing trends over time.
However, some characteristic symptoms often indicate that
a shortage is in the offing.

One bellwether of a shortage is the vacancy rate, or the percentage of budgeted positions that are unfilled.

New
England’s hospitals currently report that an average of
7 to 12 percent of their registered nurse positions are vacant,
the highest levels since the last shortage in the late 1980s.
Connecticut is in the worst shape in the region, with a vacancy
rate of nearly 12 percent; in 1996, it was only 4.5 percent.
In contrast, Vermont has a relatively low vacancy rate, at 7.8
percent. But its vacancies were at 1.2 percent just five years
ago.

Another symptom is the increased use
of stop-gap measures to fill empty positions. For instance,
many nurses report an upswing in how frequently they are asked
to stay past their shifts. According to Murphy, at St. Elizabeth’s
“the shortage has definitely created a lot of opportunities
for overtime for our nurses, whether they want them or not.”
Similarly, a national survey of registered nurses shows that
in an average week, nurses in the U.S. work 2.4 more hours
than they are scheduled for. Much of this extra time is voluntary,
as nurses earn overtime pay when they stay to fill in blanks
in the schedule. But when volunteers fail to plug all the
holes, health care facilities must occasionally require RNs
to stay for mandatory overtime to ensure enough staff are
on duty.

When they can’t fill open positions
by more traditional means, health care providers hire temporary
staff to tide them over. Itinerant workers known as travel
nurses comprise the largest part of the temporary health care
workforce, hired for thirteen-week stints at health care facilities
facing short-term deficits of workers. Temporary workers,
mainly nurses, cost hospitals $7.2 billion in 2000. Likewise,
in tight labor markets employers start to recruit staff for
permanent positions from outside their region or even outside
the United States. In 1996, 36 percent of the nation’s
RNs had received their training in a different state than
the one in which they were currently located. And 4 percent—110,000
nurses—had trained in foreign countries, mainly in the
Pacific Rim.

Declining numbers, declining trust

All the signs today point toward a
nurse shortage. But as recently as 30 years ago, there were
plenty of nurses. The influx of workers, especially women,
into the labor market in the 1970s had eased the scarcity
of nurses that had persisted since the 1940s. Women chose
nursing occupations in record numbers; indeed, the children
born in the late 1950s produced more nurses than any group
either before or since. Falling birth rates since the Baby
Boom, however, have meant that the number of people available
to go into nursing each year has decreased. At the same time,
the proportion of women choosing nursing as a career has also
declined. In the early 1970s, nearly 10 percent of women entering
college listed nursing as their probable future occupation.
By 1998 this figure had dropped to under 5 percent. (Less
than 1 percent of men listed nursing as their probable career
in both years.)

The combination of declining birth
rates and smaller proportions ofpeople entering nursing careers
means that each year we produce only half the number of RNs
we did 30 years ago, even though the U.S. population is nearly
40 percent larger today. New RNs are not being created fast
enough to replace retirees, so the population of RNs is aging
rapidly. “Forty-one percent of the RNs at my hospital
are between the ages of 50 and 59,” reports Hychalk.
“That means that by the year 2012, 41 percent of my staff
will be at retirement age.”

These changes in occupational choices
and population composition have contributed to the periodic
shortages of nurses since the 1970s, and they will continue
to play a role in declining nurse availability in the future.
But the current situation has been exacerbated by a new factor—the
effects of health care industry restructuring. Historically,
the health care industry has redistributed its employment
of nurses in response to shortages. Deficits of registered
nurses in the 1950s and 1960s, for instance, led to the specialization
of nursing duties. Before then, hospitals had used registered
nurses for just about every kind of nursing work, from feeding
patients and changing sheets through starting intravenous
fluids and creating patient care plans. But this meant that
these highly trained nurses spent much of their time—by
one estimate as much as 65 percent—on duties that did
not require their advanced level of expertise. Hospitals solved
the problem by hiring licensed practical nurses and nurse
aides to handle lower-level tasks, thereby freeing RNs to
concentrate on the more skill-intensive work that only they
could handle.

In contrast, the changing organization
of the health care industry associated with the growth of
managed care in the early and mid-1990s may in part have caused
the shortage. In the past, delivering health care services
was fairly simple; doctors performed procedures on patients
and insurance companies paid for them. But under managed care,
insurance companies and health plans attempt to reduce expenses
by establishing strict policies about which treatments and
procedures they will and will not pay for. This new organizational
structure has put health care facilities, even those not operated
under managed care, under intense pressure to reduce costs
in order to remain economically competitive.

As a result of managed care, registered
nurses in the early 1990s found themselves caught between
two opposing economic forces. On the one hand, to achieve
their new budgetary goals, hospitals increasingly focused
on providing only the most advanced and most technical forms
of care, leaving the care of less acutely ill patients to
less costly rehabilitation centers, nursing homes, and family
members. Patients in hospitals were thus sicker than ever
before, and more of them required an RN’s expertise.
But on the other hand, 25 percent of the average hospital’s
employees are registered nurses, so nursing labor is a major
expense for hospitals. RN payroll became an important opportunity
for many administrators to trim budgets in the mid-1990s.
“In 1995 and 1996, hospital RN employment declined by
38,000 workers while hospitals added 100,000 aides in an attempt
to substitute toward a less expensive form of labor,”
reports Peter Buerhaus, an RN and senior associate dean for
research at Vanderbilt University’s School of Nursing.
Furthermore, hospitals allowed wages to stagnate. Between
1993 and 1998, RN earnings declined by 7 percent after adjusting
for inflation.

“By 1997, hospitals realized that their strategy wasn’t
cost-effective,” says Buerhaus. “Patient admissions
were picking up, and the patients got older and sicker every
year.” Hospitals’ attempts to reduce costs by cutting
professional nursing staff turned out to be short-sighted.
They quickly rehired 40,000 RNs in 1997 and let go 50,000
nursing aides.

But according to Buerhaus, these cost-cutting maneuvers
had real non-economic consequences—ones that are still
being felt in the labor market today. “A lot of nurses
felt betrayed. They felt that hospitals were cutting costs
without thinking about patients or the quality of care. It
broke their trust in the hospitals, and hospitals have been
struggling to get that trust back ever since.”

What’s the prognosis?

At first glance, it seems that the labor market for nurses
is caught between the Scylla of increasing demand and the
Charybdis of decreasing supply.

There is little doubt that the demand for registered nurses
will continue to increase for years to come. The elderly population,
a major consumer of health care, is expected to increase by
60 percent by the year 2030, according to projections from the
Census Bureau. And no end is in sight for the advances in high-technology
medical care that make skilled nursing increasingly critical,
especially in hospital settings. Health care providers may be
able to find replacements for some RNs by reallocating work
to lower-skilled nurses or using more technology in place of
people. But much of what RNs do cannot be substituted for, and
in any event these types of changes won’t be enough to
completely counteract our growing health care needs. On the
demand side, for the most part, we will simply have to wait
things out.

On the supply side, however, there is more room to maneuver.
At least part of the shortage could be eliminated if wages
and working conditions for nurses were appealing enough to
attract more people to the profession. Employers seem to be
taking note of this; RN wages are starting to escalate after
years of stagnation. The U.S. Bureau of Labor Statistics reports
that from 1993 to 1997, average inflation-adjusted wages for
full-time RNs declined from $819 per week to $762 per week
(in 2000 dollars). But since 1997 wages have been on the rise,
and in 2000 they finally climbed back up to $790 per week.
Employers are also attempting to enhance working conditions
by offering incentives such as increased flexibility in scheduling
shifts and bonuses to new employees and employees taking on
extra overtime. But a lack of financial resources resulting
from cost containment measures and low reimbursements from
government programs means that many health care facilities
simply don’t have the money to support these initiatives.

Besides, it’s not just wages and working conditions
that keep people out of nursing; it’s also the public
image of what nurses do. “Nurses are extremely intelligent,
creative people; we have to be to do our jobs. But we are
not portrayed as bright, articulate, or innovative, or as
working independently and functioning at a high level,”
says Mary Anne Gauthier, professor and director of the undergraduate
nursing program at Northeastern University in Boston. As a
result, people who would make excellent nurses can be dissuaded
by misunderstandings about the nature of the job. Men in particular
seem to find the nursing image unappealing, perhaps because
the occupation has such a strong gender stereotype (95 percent
of registered nurses are female). For them, even the term
“nurse” itself may be enough to keep them out of
the occupation since, as Huet says, “Nursing has the
connotation of a baby suckling a mother’s breast.”
Others agree, arguing that the only way to interest more men
in nursing careers is to change the name of the occupation
to emphasize the professional and technical nature of the
work.

Enticing more people into nursing will be a challenge. Nonetheless,
some area organizations are tackling the issue. For instance,
Northeastern University in Boston has developed an accelerated
baccalaureate nursing program for more mature students who
have already completed the science prerequisites for a nursing
degree. The accelerated program can mint a certified bachelor’s-level
RN in less than three years, compared to five years for students
in the regular program. The Merrimack Valley Area Health Education
Center in Lawrence, Massachusetts, is filling its community’s
need for registered nurses by helping academically underprepared
students interested in nursing careers to bridge the gap to
college. And the Nursing Career Center of Connecticut is working
toward creating a positive public image of nursing by promoting
nursing careers to kids as young as elementary school age.

Health care providers are also finding new ways to recruit
and retain staff. Some are investing in technology such as
patient lifts that reduce the physical strain of nurses’
duties, thus helping older nurses to stay on the job. Some
are hiring more support staff like respiratory technicians,
pharmacists, and dieticians to remove these burdens from the
RN workload. Some are offering scholarships or grants to encourage
people to choose nursing careers. Northeast Vermont Regional
Hospital has taken an innovative approach, forming an alliance
with two state colleges to create the first nurse training
program in the area in 30 years. The 16 students who entered
the program in 2001 are taking courses at the colleges and
will do their clinical rotations at the hospital and other
local health facilities.

Even the resources and attention of the public sector have
been brought to bear on the issue. The state of Vermont, for
instance, offers annual scholarships of $7,500 to nursing
students who practice in the state for two years. Massachusetts
is considering proposals to establish limits on mandatory
overtime, to forgive nursing student loans, and to provide
bonuses for experienced nurses who serve as mentors. And the
proposed federal Nurse Reinvestment Act, if passed, would
provide nursing scholarships to students who agree to work
in underserved areas for two years after graduation.

Will all these efforts be enough? Only time will tell, but
some say we should think bigger. Buerhaus, for one, would
like to see a billion-dollar public image campaign for nurses,
along with government aid for nursing schools on the brink
of financial collapse, for hospitals redesigning the ergonomics
of their work environments, and for students going into nurse
training programs. But in the end, any successful solution
to the shortage depends on convincing more people to become
nurses, and that is no easy goal to reach. To achieve it,
says Buerhaus, “society needs to place more value on
nursing. Legislation can’t do that—it has to come
from people.”

RNs, LPNs, and NAs—oh my!
A nurse is a nurse—or is there more to it? The staff
providing day-to-day care while you’re sick might be
nurse’s aides with two weeks of training, or they might
be advanced practice registered nurses with six or more years
of professional training, or just about anything in between.
Things were different at the advent of professional nursing,
when the same nurse performed every element of nursing care,
from feeding and bathing patients to monitoring vital signs
to creating patient care plans. But today nursing work has
been divided among four major types of nurses, each with different
levels of training, certification, and specialization.

Registered nurses (RNs), who work in the largest health-related
occupation with over 2.2 million workers nationwide and 148,000
in New England, are the most diverse in terms of their preparation
and skills. They may have received their training from a two-year
associate’s degree in nursing program, a three-year hospital-based
diploma program, or a four-year baccalaureate nursing program.
In clinical settings, their advanced skill level allows them
to perform more complicated tasks such as assessing symptoms,
administering medications, and educating patients. Clinically
based RNs may further specialize in clinical areas such as
pediatric intensive care or adult critical care. Other nurses
work outside direct patient care in fields such as research,
patient education, and administration. Because they are so
highly skilled, RNs are in high demand in hospitals, which
provide the most complex types of care. Registered nurses’
median earnings were about $41,000 per year in 1998.

Advanced practice nurses (APNs or APRNs) are a subcategory
of registered nurses numbering nearly 200,000 workers nationwide.
They have completed a baccalaureate degree and then have gone
on for several more years of postgraduate training to become
nurse practitioners, clinical nurse specialists, nurse midwives,
or nurse anesthetists. Depending on their specialization,
they earn anywhere from 20 percent to 120 percent more than
the typical staff RN; the highest salaries go to nurse anesthetists
at about $90,000 per year.

Licensed practical nurses (LPNs) provide basic bedside
care in hospitals and nursing homes. They may take vital signs,
give injections, apply dressings, or simply observe patients.
Their training typically takes about one year at a community
college or vocational school and includes a combination of
classroom study and clinical practice. They then must pass
a licensing examination before they can join the LPN ranks,
which number 36,000 in New England. Once their training is
complete, they can expect to earn an average of $27,000 per
year.

Nurse’s aides and home health aides (NAs/HHAs),
numbering 130,000 workers in New England, are the least-trained
nurses. They receive 75 or more hours of instruction in basic
health care provision, typically at a high school, vocational-technical
school, or community college. Those who work in nursing homes
receiving Medicaid funding must pass a competency examination,
but there is no official licensure in this occupation. Their
job duties include serving meals, tidying rooms, and helping
patients to eat, dress, and bathe. The average income for
an aide working full-time, year-round in 1998 was about $16,000.